MCHB/DHSPS April, 2008 Webcast
Care Coordination Reform: Connecting at Risk to Care
>> Good morning. On behalf of the division, I would like to welcome you to this web cast entitled "care coordination reform, connecting at risk to care." Before I introduce our presenters toe, I would like to make some technical comments. Slides should advance automatically. They will synchronize with the presentation. You do not need to do anything to advance the slide. You may need to adjust the timing of the slide to match the audio by using the slide delay control at the top of the messaging window.
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Today we have two presenters. First is Dr.
Mark Redding, who is the medical director of the community health access
project. Following him will be Rick Wilk, the
director of the
My wife is a physician as well and we work together in this work towards helping connect at risk people to care. And she travels and she was leaving for a particularly long trip several months ago and was going to be gone five or six days. My little boy, the night before she was leaving, he ran to her room and asked if everything was in his star wars book bag because he's particular about everything being in there in the morning. She said, well, David, your father is going to be in charge while I'm gone. You go ask him. And so he did. And I said, well, Dave, what goes in your star wars book bag? And he made an awfully sad face and left the room and later on that evening, he had a heart to heart with his mother and he said, mom, if anything ever happens to you, he's going to have to get remarried right away. So with that, realizing we're all human beings and all have our own role, next slide, please.
I would like to challenge you and discuss
with you a particular dilemma and crisis that I believe exists within our
health and social service system. Starting this presentation with the end of it
in mind, what we believe needs to happen is that we need to find the people who
are at risk. At risk for health, social, educational,
behavioral health conditions. We need to assure that they are treated
and treated with evidence based intervention treatment that has a basis for
working and we need to measure our results and do that faster and better and
smarter. What I will present, those most at risk and
I've been involved in this work more than 20 years now. They're in the back of
trailers, back in the dangerous urban housing complexes. They represent the
greatest waste of our health disparity our nation and we are not reaching them
and we are not connecting them to care. And I would ask how could we have the
most extensive health care system in the developed world and not reach those
that need the services the most? So possibly simplicity can help us in this
highly complex system of ours. I'm not very good at it and it's taken a lot of
work to help focus in that area but trying to find simplicity, how do we
organize this? One way of looking at it, and we can throw this out at the end
of the presentation. One way to organize it is to find and connect to care can
be seen as care coordination and it's defined in the latest academy of
pediatrics policy statement as essentially the work that happens outside of the
-- between the doctor's office waiting room or the hospital waiting room and
the person's home. And it is a part of the system that in many ways, especially
quality we have ignored. So that part of the system, the finding the person and
connecting them to care is the focus of this potential reform effort. The direct services, that's the cat scan, the lab test, the
doctor's visits, the diabetes followup, hemoglobin,
you name it. The final step is improvement as we move forward. So one way just
to help the conversation is to say that the health and social service system
has direct service component and has a care coordination component and
obviously they are interwoven but there are advantages to breaking it out this
way. I think the other thing you'll find in this discussion is an individual
based approach. And this is not to recognize the very important intervention of
population based health policy. In other words, not smoking in restaurants and
fluoride in the water and safer sidewalks, absolutely, we need that. But we
also need to make sure we do good individualized assessment and intervention.
As a pediatrician, it would be great to go in the waiting room and serve a
particular type of cookie or spray something in the air and everybody out there
would be OK but that's not how it works. It's actually only through careful
assessment and identification of the evidence based packages that people need
that healing can be realized in that setting. So how -- essentially care coordination
has been termed social work. It's the part of the health care system that us
doctors have not been interested in. We're more interested in our 10 to 15
minute visit. How did I get interested in it? My grandfather had been a
missionary. I wanted to be one, too. My wife and I headed for
Next slide. I think we can also take pride in the fact that we spent more than any other developed nation and this slide is a little out of date because the situation is much worse now and ranked us against the five countries with the best basic outcomes for health. I think what is particularly disturbing about this slide is if all of that money we're spending purchases goods and services to have an impact on health, and we're spending twice as much of it as any other nation in the developed world and we have the worst results, where is the money coming from? And sadly, it's coming from American business which is very accountable for its products and services and cannot afford this expenditure from the waitress to the private business leader who is moving his company overseas, substantially related to the cost of health care. And it does not obviously point to something that needs to be tweaked or adjusted but fundamental change. Albert Einstein said we can't solve today's problems by using the same kind of thinking we used when we created them. We've created a pretty big problem and I don't think it points to any one agency. It's from the information and from the way we're looking at it, it points to all of us. We're each involved. We're each part of it. I would like to highlight, for example, Medicaid which is just one of all of us but the cost per Medicaid has tripled in just a little bit more than 10 years. Basic outcomes in my state are worse than they've been in 20 years. Something is wrong. So let's look at the fundamental basic components of our system. Is it the treatment services that are bad? You know, I have no idea there are some bad but in general, we have the best evidence based interventions in the world. We have diabetes intervention, cardiac intervention, obesity education, prenatal care, people fly in from all over the world. These interventions are benefiting substantially our wealthy population. They simply are not -- these packages of evidence based care are simply not connecting to those who need it the most. I would like to just highlight one example so that -- to make sure you're thinking is broad enough in this category. The Australians have developed an education packaging for parenting called triple peace. You go to a course and you get the materials and you become a triple t provider. What is interesting about it is I take the same course that a community health care worker would take, a counselor would take. Once you've taken the course you deliver this package of parenting education to parents that teaches them to handle discipline correctly but to primarily focus on their child's strength and what's great about that child. Substantial improvement in school performance, close to 50%. Substantial reduction in ADHD. Possible until terms of long-term outcome for everything from employment to some of the neighborhoods we work in with more than 50% of males going to prison, imagine what this kind of evidence based intervention delivered to families in a culturally appropriate way could do and it's certainly helped me as I have struggled with my own similar situation says. So we have the packages. Realizing the care coordination is much more complex than this, but looking at it like Fed Ex, we have the packages of evidence based intervention. There's no need -- I mean, I'm not saying not to continue research but we have a lot of research showing what works, what doesn't work. What we need to focus on is like Fed Ex, making sure that everybody, not just the wealthy, get the packages. So this is just a small low scale intervention which is one of many and there are many and I want to mention, for example, Mario German's program was in the healthy start program. It was far greater than what I have to present to you here but I'm going to use this as an example. In our own county, we were told that there really wasn't a problem with low birth weight because it was about the same as the state average but then you have to remember that we're the worst in the developed world to put that into context and then you have to remember that my wife got pretty fired up about that and she got every birth certificate in the county for five years and plotted it. And we found census tracks in our own county where low birth rate was actually approaching 24%. And they were within the most impoverished. We know where the most at risk are. This part of it is a piece of cake. We identified individuals from part of the community. We trained them with college credit. I've brought some of our training materials. There are many other such examples across the country. We support them with nurses and physician backup and next slide, please.
They reach out from a central community
setting. These individuals know 40 to 60% of the families before they even
knock on the door and it is in the center of the little blue dots that you saw
on the previous page. We thought we would teach them a great deal but actually,
the teaching happened far greater on their teaching us. What they taught us was
even though that center is just a few miles from the office,
it's more than a few hours by bus. You're traveling there on a cold day or a
hot day with a bunch of kids and the buses or the transfer runs late. At not
only my own office but nine others, if you're 15 minutes late, we send you
home. We need to teach these people responsibility, it's said. Just another on
the ground example of us rich people or wealthier people trying to teach other
people something when we have no idea of the context in which they come from
and what they're struggling against. These are not the only barriers that our
community health workers taught us. If you have a 17-year-old and she's
pregnant and she lives in the back of a housing
complex with no phone, with a little card table and an eviction notice on the
table and another small child to look after and it's March, her prenatal visit
probably isn't her number one priority. Those of us who built the system do not
have the context and we need this wisdom. We began addressing housing and food
and clothing and partnered with close to 40 churches now in this area to help
provide for those issues. The other partners we've developed and I think this
is also a new partner in these kind of initiatives is American business. A gentleman
named Samuel Starr who we caught between jobs as a volunteer but who later was
in Forbes magazine for redesigning sterling commerce as a global internet
consultant and software provider told us that if we were going to have a
program that provided an intervention, we first needed to very carefully define
what it was we were going to do and how it would be meaningful to our
customers. And what he identified was that in our current system, what we
produced was a number of visits, number of charts, number of progress notes,
none of which have any meaning to the person served. So we developed a model
that just mirrors American business and it captures the steps that again are
meaningful to the client and they, again, this is all
focused within care coordination. I am not here to promote this model anymore
than I'm definitely here to promote that in care coordination, you need to
define what is meaningful to the person you serve and make sure you do that.
And I brought some of these pathway cards and they're also on our website but
this is the kind of thing that our care coordinators carry around and live and
breathe by. There are over 40 of these pathways in production not only in our
agency but approaching 100 other agencies and the way this kind of thing can
fit into your own care coordination approach is -- I'm sure most care
coordination programs do an assessment and ours is several pages long. It's
health, mental health, social issues, behavioral health and others. But where
that landed prior was those issues identified within our plan of care. Where
they land now is if you're homeless, you're on a homeless pathway and we've got
key benchmarks to make sure you get basic education, that
you're confirmed to connect to housing and the pathway ends with a specific
result and so housing is an example. You would not complete the pathway until
the person had secured housing. If the pathway is pregnancy, the at-risk person
is identified, they're provided evidence based education related to pregnancy,
their barriers are understood and it is not done until they have been confirmed
to connect to prenatal care and finally have delivered a baby that is greater
than five pounds, eight ounces. So it's a structure where you can build what
you think is meaningful and you can construct the outcomes or the results that
you want to achieve and then each client may have -- our most at-risk clients
may have 30 of these pathways dealing with health and social issues and in each
case if you consider our second slide of finding at risk, treating the at-risk
person and measuring the result, we are in each pathway identifying the
problem, ensuring that they connect to something meaningful to address that
problem and we're measuring the result. What we found on implementing this exciting
model was unfortunately we weren't producing very many of these. We had been
previously able to impress our funders with a number
of clients, a number of services, all of the different things we were doing but
when it really came to producing these results, we had very few. We again
hooked up with our American business colleagues and what we did, interestingly,
that had the most substantial effect was we began to tie our own contracting to
the achievement of these results. And we began to tie our employees' incentives
to achieving these results. So Juanita, one of our top performing community
health workers in
The next slide shows our rate of low birth
rate reduction. In census tracks where low birth rate was over 20% for enrolled
clients, we began, over time, to see a low birth weight rate less than 5%. This
has not been compared to an adequate control group, although in collaborating
with other researchers we've been told it's the most at-risk population of
pregnant women they've ever seen in terms of other risk factors like smoking
and previous pre-term infants and others. But this, although in so many ways
this is a critical slide and the outcomes for our patients are what we want to
achieve, it's actually not the most important part of what I have to present to
you today because obviously, if we connect people to evidence based
interventions that they need, they're going to have better results. So what is
most important about the presentation today is not the fact that we have
achieved better health outcomes, others have done that far better than we have
done in a research perspective. What we have done and what is represented in
this presentation and by we, it's a pretty far stretch. Other
partners across the
>> Thank you, Dr. Redding. Now we'll have some comments from Rick Wilk. Are you still there? Rick?
>> Rick, break in whenever you get access and we'll move on with questions.
>> Right now we don't have any questions online unless you have any question in the room.
>> I think one thing about incentives
that is really important not only for individuals but for agencies
is it really helps if you start with new money. So you don't take -- you
don't pull out their current pay, whether they be an individual or a program,
you come up with something beginning to be new and that helps them learn how to
operate in that kind of setting. Once they get good at it, you can actually
move more of the financing related to incentives and the people who -- the
agencies and the individuals doing well with that won't mind a bit because
they'll actually make more money. So you start with new money. You make it
fair. You've got to consider cash flow so, for example, for the pregnancy
pathway, when the care coordinator finds and engages and does all of the
paperwork on the at-risk patients, it's really a process item but a critical
one. There's a payment. Recognizing the cash flow has to get started. When they
connect, when they are confirmed to connect to prenatal care and this is
written in the article that is made available through the resources here, when
they have confirmed to connect to prenatal care, another payment is made. But
to be honest, we're learning how to do this in
RICK WILK: Mark, I apologize. I could not hear you when you called for me so I'm glad to step in whenever you would like me to say a few words.
>> Rick, please go ahead.
>> OK. Well, I guess a few things I would like to share is that after hearing mark's -- what mark has shared, I think that we really have an opportunity and a strong need to identify those most at risk. And if we really want to impact health outcomes, I think we're going to have to spend more of our time, not all of our time but more time identifying those most at risk and of course, we're increasingly understanding the value of delivering evidence based services to those most at risk. I think it's critical, of course, to follow up to review, that delivery of the evidence based services, make sure they really are delivered and to -- I think we increasingly have to start looking at measuring health outcomes as challenging as that is. I think if we don't think of outcomes at least some of the time, we're not going to move closer to the ultimate goal. And I think that the thing that mark is sharing, which I think is very challenging for so many of us to consider doing is linking our -- looking to connect outcomes to payment. That is very challenging and I think any time you talk about money, funding, grants, it creates some challenges but I think mark has shared how this can be done and how it's working. I've seen other communities begin to play with this and it does get people's attention and it does get at least some focus on outcomes and I think until we start focusing on the outcomes, we're not going to be producing them in the way we would like. So I think trying to find ways to tie the contracting to the achievement of results, be the outcomes or other type of intermediate results, is extremely important. I guess the last thing I would share, in watching the reaction communities have to the -- these concepts, when Dr. Redding shares them and this is typically coalitions, not individual providers, it's at first challenging for many participants but I see typically a number of organizations will step up with great interest and in time, very often, we've been really bringing a coalition together because while this approach is quite bold, it really touches the heart of what we want to accomplish in health care which is to improve health outcome. And it brings different types of organizations together in ways that we're not used to working which, of course, presents some challenges but it also presentations some extraordinary opportunities.
>> Thank you, Rick. And I think Rick is an example of an individual within our health and social service system very committed to achieving health disparity and there are individuals throughout our health and social service system that want to see it change and want to see it work. And with love and kindness, we need to make -- we need to see that happen. Thank you, Rick.
>> You're welcome.
>> Thank you, Rick. We do have a couple of questions online. The first question is, what does it cost to provide service to those at greatest risk? You mentioned it takes three or four times more to serve them.
>> Well, interestingly, it takes much
less than what you're paying right now. I mean, what you're paying -- if you
take a care coordination contract and we are evaluating them in
>> The next question is a bit broader question. Would you say that most of the healthy starts have a good system in the state?
>> I would say that the one that I
know, that I've read about the most is Mario German's program in
>> Sorry for the long answer.
>> No. No. No problem at all. Actually, to pick on your profession a little bit more, recruiting question, how do we get more physicians on board?
>> You know, the way care
coordination -- I've got to admit, there are definitely physicians who connect
with care coordination. But most -- our experienced physicians are in our
services. From the waiting room through the office and the hospital, we're
connected. But my grandpa used to go to your house if you got sick but we left
that quite a while ago and we have left the care coordination business in some
respects. What is interesting is
co-ordinations. As people don't connect to our care, we lose money. The other way that they're affected is physicians, just like care coordinators, they are penalized because they're paid based on time, not how sick the person is. So if I take in this homeless, pregnant 17-year-old and I would be looking after her baby, that's going to take me -- to provide good care and to do the right thing is going to take me a lot more time so I'm -- if we look at the business offices, physician offices, they have to limit the number of at-risk people they serve. What is fascinating from a policy point of view, if you build the incentives right, we would be tripping over ourselves to serve those most at risk. 5% of the population represents 50% of the cost. That 5% of the population is who we need to be at the door serving and there's many models to do it and the incentive structure should be built to support the physicians who against the financial system are serving those folks anyway and to make it doable. Especially as far as the prices have been, it's $36 for a pediatrician that is the Medicaid patient. That's what you get paid and you have overhead and other stuff and I'm not here to request more physician payment but my point is, incentives could be developed for physicians along the same lines and we could begin to develop a better system of care for those most at risk. Questions are awesome.
>> Question kind of related to your
incentives which you already brought up. How do you work with agencies that
each have their own measures, mandate the care coordination, often
don't have incentives to work together? >> Another great question. Maybe
I shouldn't say this but there's a feisty attorney in
>> Thank you. In reducing duplication of care coordination services, how do you ensure that a single provider has the needed experience to address all of the client's needs? For example, prenatal care management and mental care.
>> I think that's an excellent question and I think that's where some of the intervention needs to come in. There are good reasons for the client to have duplication of service. You know, they need a special diabetes nurse or they need a special behavioral health intervention like you just said. But the key is like a business, you know about that duplication. There's a purpose for the client and it's not just duplication. It's not just a bunch of people essentially doing the same thing. But what is interesting about care coordination in its most basic form is that there needs to be standards. There needs -- you know, you can't have somebody in somebody else's home that has a criminal background that would put you at risk as an agency for employing them. And that's just a cuff technical example, although there are some things on people's records that can be overcome that way, if you know what I'm saying. But you need to have standards in Ohio, and I've given the resource, the Ohio board of nursing has put their standards for community health workers who are generally people in part of the community served and their standards are online, you know, requiring background checks and other things so there needs to be basic standards. But if your focus is making sure problems are identified and people are connected to care, you can send out a pretty broad range of professionals to complete assessments they've been trained to do and then if you take the community health worker, for example, when they find out the person is pregnant or when they find out the person has aids or they find out the person has not had any shots in a long time, they bring that assessment back to the nurse or back to the other professionals, which is exactly how Alaska works and somebody at the appropriate level of training then makes decisions based on that assessment and they go out and see them. But I think what you're pointing to is quality. We need to have a strong sense of quality and there are examples, again, across the country to do that and good question. Very good.
>> More of a content related question. Can you speak more about the content of the timing of the community health aid?
>> Sure. It's listed in great detail
online by the
>> Thank you. Actually, where can you find additional information on the fiscal model you referenced is structured?
>> I think the best example of that is the Columbia university voices article published a couple of years ago, and again, we are not a university center and I wish we had so many more publications but this is one that focused on the incentive model and the hub model and it's accessible under our website. Pages three and eleven are the ones particularly that highlight the funding model and then my email address is on there, too, so feel free to contact me and I would be happy to -- my work with this is primarily volunteer other than some consulting and expense related stuff and we're on a mission to do this together and so most of what is out there is not in any way proprietary or limited so --
>> Thank you. Do you have any questions in the room? No? OK. There is another question. What can programs do with the outcome data to influence policies?
>> Great question. Man. You know, that is the interesting thing about this. Us programs have got to do what you just said. We've got to show, and I know this sounds -- but we've got to show the policy makers that it can be done. Except the hardest challenge has been to get the funders to actually increase their accountability in the contract. The hardest part of this has been to get the funders to make this request. And I know that that sounds silly, but funders fund essentially constituents who get mad. And if they do it wrong, they can get really mad. And what is interesting is, there is a way, and we need a lot more time to discuss it. There's a way in a supportive way to actually help grow these agencies and grow the service system and care coordination and not make anybody mad unless they're absolutely not doing anything to help anybody, which it's OK if they're mad. But the large majority of them, it's possible. So we've got to do exactly what you said. Come up with meaningful benchmarks for the people that you serve that are measurable, that are accountable. Look at what you -- it costs you to produce them and this is obviously very timely so show what it costs for you to produce that product. Whether it was the person getting housing or food or clothing, whether it was prenatal related, diabetes related, behavioral health related and then come up with cost comparisons to show what would happen if you won't. And create your own production model of these specific services at risk people and what is being saved and I think what would be great would be to be some league of these funders, these bold funders that they're going out on the furtherest limb that I've seen anyone go. They're having the hardest time with this. Very good question. Please feel free to email me with other questions related to that.
>> OK. I really appreciate this
question. I don't want to minimize the information technology. But I think it's
really critical that it not be about that. It needs -- and you'll see why,
hopefully why I'm saying this. What our focus needs to be is finding those
people who need the help and connecting to them in care. What I've seen happen
is everybody has created a whole structure but it's built around a data base
and that all wasn't focused on serving the person. She's still not getting the
prenatal care. What we're recommending to communities is that when they build
this thing that they actually start with a paper system and again, people can
do it however they want. I think if they're technically savvy and have the
resources, most of these communities have very limited technology resources but
-- so they start with a paper system and what that forces them to do is keep it
really simple. So in
>> You mentioned policy. You can have people -- community outcome that is really the practices behind those outcomes.
>> I hear you. I think you could talk -- there could be a lot of detail related to that but if it's care coordination, if we went sort of right down the list, quality measurement, the first measure of quality would be, was the person at risk? In other words, were you serving somebody who lives in a $500,000 home who has lived -- whose chances of a low birth weight baby is 3%? One measure of quality is to make sure we're actually giving people services they need and that it's focused on somebody who needs it. The next would be in most of these care coordination approaches, there has to be health education component and that's got to be quality based. If you have somebody providing just off the cuff health education, I've seen some scary examples of that. And it needs to be -- that needs to be evidence based, it needs to be in a package and the person delivering it absolutely can be from the community or church or whatever but they need to be trained as to what they're delivering and they need to have whatever myths they're walking into it addressed. Then I think it's a measure of quality that you fully assess the patient and what their barriers to care are, things like language and transportation and culture and behavioral health and they were sent away from the doctor's office and they're afraid. And then a payment point for us, and possibly our most significant measure of quality for care coordination and fits with other national standards which really aren't utilized much but that they actually receive the care. We have people with 3,000 pages of chart notes that never actually connect to the service. And then we shouldn't hold care coordinators 100% responsible for all outcomes because they don't control that completely. But they certainly should measure the final outcome and look at it and it can be part of the payment structure as it is -- care coordinators that have normal birth weight babies in our system actually get -- the program and the coordinator get a higher payment. It's an incentive structure. It encourages them to get them to stop smoking and get the care they need.
>> A broader policy question. I'm just curious your take on this. You mentioned about focusing and just a minute ago you talked about focusing on those most in need of making sure their needs were met first. Since last August there have been some interesting arguments about Medicaid and the participant of that or one of the participants was a letter that went out from Medicaid services to states saying you may no longer expand the level of -- increase the percentage of poverty level for programs unless you can show that 95% of those eligible for Medicaid are, in fact, being served. It sounds similar to what you're saying. Saying in the community you want to be sure that those who are in the back of the housing project, the ones who are most difficult to find are being served. Well, we could argue that that is what the federal Medicaid program is doing now. However, the push back from states have been that there are others in need and what you are doing in effect. Because we can never get to that 5%, you are in effect preventing us from serving others who we could get to. How do you deal with that issue?
>> That's a beautiful question. Now,
and I want to focus on the last thing that you quoted or said is that there are
people that are not served but we're never going to reach them so we need to
move on to others. And the point being there, that is what has been said -- I
can't tell you the struggles some of these -- we've got leaders, we call them
community change agents and developed through HRSA in substantial part that are
pounding on their communities and dealing with these issues right on the front
lines. And what they so often run into is they begin to focus on at-risk, they
find the at-risk population but everybody says we tried to serve those people
and we can't so we're moving on. And essentially there, the individuals that
will not utilize the service the way we have put it forward, you know, in other
words, we've essentially put forward a store front of health care. It's like
building 1,000 Wal-Marts or whatever. The basis of
the store front is built by not people in poverty but built by the rest of us
who have cell phones and are comfortable going to doctors. And then if people
don't connect to our store front, we blame it on them and we say, oh, well, you
know, we put up this beautiful store front and then the primary incentives in
most of the contracts is they not use it. There's greater payments to those who
provide the system of care if people actually don't shop at Wal-Mart which is
another huge philosophical problem with the structure. So within that group
that you just quoted that just can't be served, they can be served. And they
can be reached. But different strategies are needed and strategis
that can reach people in poverty,
>> Do we have any other questions in the room? There are no more questions online.
>> I appreciate so much the questions and the engagement and I really appreciated this dialogue and learned a lot. Thank you.
>> On behalf of the division of healthy start, I would like to thank Dr. Reding and other audience. I would like to thank our contractors who made this work. We encourage you to let your colleagues know about the website. We look forward to your participation in future web casts.